Limb-Shaking Transient Ischemic Attacks Masquerading as Focal Seizures.

Abdullah Alkutbi,Ahmed Elkady

doi:10.7759/cureus.8157

Abstract

Limb shaking is a paroxysmal involuntary hyperkinetic movement that may be a presentation of severe unilateral steno-occlusive carotid disease. This unusual form of transient ischemic attack (TIA) is often misdiagnosed as focal motor seizures, especially with frequent repetition. We present a case of 67-year-old man with severe unilateral carotid stenosis leading to frequent left arm shaking TIAs. Initial work-up did not reveal any abnormalities, and anticonvulsant was started. He readmitted again after few days with left side mild hemiparesis. Cerebrovascular evaluation showed recent watershed infarction with significant stenosis in the ipsilateral internal carotid artery (ICA). The patient underwent stenting of the right ICA with weakness improvement and no more limb-shaking TIA on follow-up. In conclusion, early recognition of limb-shaking TIAs and differentiating it from focal motor seizures can facilitate identification of pre-occlusive carotid stenosis, allowing for appropriate interventions to prevent further TIAs or disabling stroke.

Highlights

Transient ischemic attacks (TIA) are typically present with various neurological symptoms, including motor, sensory, speech, or visual deficit attributed to perfusion insufficiency
We report a case of limb-shaking TIA being first treated as focal seizure, before a high-grade stenosis of contralateral internal carotid artery (ICA) was identified as the cause of these intermittent movements
A diagnosis of low-flow TIAs presenting with limb shaking, as a result of cerebral hypoperfusion, was made; the patient received intensive medical therapy including dual antiplatelets with high-dose statins and we started to withdraw antiepileptic medications

Summary

Introduction

Transient ischemic attacks (TIA) are typically present with various neurological symptoms, including motor, sensory, speech, or visual deficit attributed to perfusion insufficiency. Doppler ultrasound and magnetic resonance angiography (MRA) of the cerebral vessels disclosed severe stenosis (>90%) of the right ICA at the level of the bifurcation (Figure 1B) At this point, a diagnosis of low-flow TIAs presenting with limb shaking, as a result of cerebral hypoperfusion, was made; the patient received intensive medical therapy including dual antiplatelets with high-dose statins and we started to withdraw antiepileptic medications. A diagnosis of low-flow TIAs presenting with limb shaking, as a result of cerebral hypoperfusion, was made; the patient received intensive medical therapy including dual antiplatelets with high-dose statins and we started to withdraw antiepileptic medications He was referred to our neurology interventionist for urgent stenting of his symptomatic right ICA, in order to prevent extensive brain ischemia or total ICA occlusion.

Discussion

Conclusions

Disclosures

Findings

Fisher CM